Optimizing Brain Health of United States Special Operations Forces.

United States Special Operations Forces (SOF) personnel are frequently exposed to explosive blasts in training and combat. However, the effects of repeated blast exposure on the human brain are incompletely understood. Moreover, there is currently no diagnostic test to detect repeated blast brain injury (rBBI). In this "Human Performance Optimization" article, we discuss how the development and implementation of a reliable diagnostic test for rBBI has the potential to promote SOF brain health, combat readiness, and quality of life.

[Pyroban on New Year's Eve 2020 & 2021 - Analysis of firework-related injuries over the last 12 years]. / Pyroverbot Silvester 2020 & 2021 ­ Analyse von feuerwerksbedingten Verletzungen der letzten 12 Jahre.

There is an increase of firework-related injuries in Germany at the turn of the year. With regard to hearing, a distinction is made between blast (BT) and explosion trauma (ET). The study examines the prevalence and characteristics of firework-related injuries and the impact of the COVID-19-pandemic pyrotechnic ban on New Year's Eve 2020/21 and 2021/22 compared to the 10-year period prior to the pandemic.A retrospective chart review of all patients who presented themselves with the diagnosis blast trauma (H 83.3) or explosion trauma (T 70.8) at the Charité emergency service in the last 12 years from Dezember 28 to January 5 was performed.276 patients were recorded, 77% of whom were male. 1/3 each were assigned to the age group 10-19 and 20-29 years. 21% of the patients were admitted to the hospital. There was an isolated BT of the ear in 67%, hand injuries in 11%, head injuries in 8% and eye injuries in 4%. 87% had ear involvement with hearing loss; 5% of these with ET.8% of the patients underwent surgical interventions. The treatment of a tympanic membrane perforation was carried out by: 54% splinting, 38% tympanoplasty. Therapy with a glucocorticoid was administered i.v. in 48%. and initiated orally in 20%. Overall, there was a nearly 75% decrease in injuries in 2020 and 2021 compared to the previous 10-year period.The use of fireworks leads to increased utilization of health care resources. The ban on the sale of pyrotechnics as well as the introduction of pyro ban zones in 2020 and 2021 led to a relevant decrease in injuries. 2020 and 2021 were the only years in which there were no injuries in children. The BT of the ear is the most common firework-related injury.

Oral and Maxillofacial Injuries Associated With E-Cigarette Explosions: A Systematic Review and Management Guidelines Proposal.

PURPOSE: E-cigarettes have become increasingly popular devices used to consume nicotine in recent years. There is a growing body of evidence regarding the risk of spontaneous explosion of these devices causing burn and projectile injuries. The primary purpose of this review was to summarize all injuries to the oral and maxillofacial region secondary to explosion of e-cigarettes. The secondary purpose was to propose an initial management algorithm for such injuries based on the findings in the literature. This review also aims to test the hypothesis that e-cigarette explosive injuries to the oral region were associated with an increased risk of intubation and surgery and examine whether any other injury pattern was associated with an increased risk of intubation or surgery. METHODS: A cohort study based on identifying cases in the literature was conducted to summarize injuries to the oral and maxillofacial region and examine the associations between injury types and location and management. A literature search of the major biomedical databases was conducted in September 2022 using terms such as e-cigarette, explosion, blast, trauma, and burn, among others, which yielded 922 studies. Nonclinical studies, review articles, and studies without injuries to the facial region were excluded. Study subjects were recorded for demographics, device characteristics, injury mechanism, injury location, management, and complications. Chi-squared analysis was used to determine if the predictor variables of type of injury (burn or projectile) and its associated location (ocular, facial, or intraoral for burns and facial thirds for projectile) were associated with the outcomes of intubation and surgical management. The collected data were then used as a guide to propose an initial management algorithm for these injuries. RESULTS: Twenty eight studies, including 20 case reports and 8 case series met the inclusion criteria. A total of 32 explosions of e-cigarettes to 32 patients caused 105 recorded injuries to the facial region. Projectile injuries made up 73.3% (n = 77) of all facial injuries, while burn injuries made up of 26.7% (n = 28). There were 14 (43.8%) patients who suffered both projectile and burn injuries. Burn injuries mostly involved the face (64.3%, n = 18), oral cavity (25%, n = 7), and eye (10.7%, n = 7). The majority (81.8%, n = 63) of projectile injuries occurred in the lower facial third. There were 20 (62.5%) patients who suffered a bone or tooth fracture. Management of injuries involved surgery in 62.5% (n = 20) of patients, which included open reduction and internal fixation of fractures, dental extraction, bone and skin grafts, and ocular surgery. A complication rate of 44.4% (n = 8) was observed across studies that reported on follow-up. There was no statistically significant association between explosive injury to the oral region and intubation or surgical management. There was also no other statistically significant association between any other injury type and location with intubation or surgical management. CONCLUSIONS: E-cigarettes are at risk for spontaneous combustion that can cause serious oral and maxillofacial injuries, particularly to the lower facial third and commonly requiring surgical management. Safety of these devices should be improved through increased user education and regulation.

Thunder and lightning-a report on firework-associated acoustic trauma at New Year 2021/2022.

BACKGROUND: This cross-sectional study aimed to assess the frequency and type of firework-associated acoustic trauma occurring in Germany on New Year's Eve 2021, despite the ban on firework sales due to the COVID-19 pandemic. MATERIALS AND METHODS: The survey period lasted 7 days, from 28 December 2021 to 03 January 2022. A questionnaire inquired date, type and treatment of trauma, sex, and age of the patient, and whether the trauma occurred when lighting or watching fireworks. Hearing impairment was classified according to the World Health Organization (WHO grades 0 to 4), and concomitant tinnitus, vertigo, or other injuries were recorded. The questionnaire was sent to the otorhinolaryngology departments of 171 hospitals in Germany. RESULTS: Of 37 otorhinolaryngology departments, 16 reported no and 21 reported 50 patients with firework-associated acoustic trauma. Mean age was 29 ± 16 years and 41 of 50 patients were males. Of these 50 patients, 22 presented without and 28 with hearing loss, 32 reported tinnitus and 3 vertigo; 20 patients were injured when lighting fireworks and 30 when watching. Hearing impairment was classified as 14â€¯× WHO grade 0, 5â€¯× WHO grade 1, 4â€¯× WHO grade 2, 2â€¯× WHO grade 3, and 3â€¯× WHO grade 4. Inpatient treatment was received by 8 patients and 11 suffered from concomitant burn injuries. CONCLUSION: Despite the sales ban, some firework-associated acoustic traumas occurred at New Year 2021/2022 in Germany. Some instances led to hospitalization, but an even higher number of unreported cases can be assumed. This study can serve as a baseline for further annual surveys to raise the awareness of the danger of seemingly harmless fireworks for the individual.

Crosstalk between Inflammation and Hemorrhage/Coagulation Disorders in Primary Blast Lung Injury.

Primary blast lung injury (PBLI), caused by exposure to high-intensity pressure waves from explosions in war, terrorist attacks, industrial production, and life explosions, is associated with pulmonary parenchymal tissue injury and severe ventilation insufficiency. PBLI patients, characterized by diffused intra-alveolar destruction, including hemorrhage and inflammation, might deteriorate into acute respiratory distress syndrome (ARDS) with high mortality. However, due to the absence of guidelines about PBLI, emergency doctors and rescue teams treating PBLI patients rely on experience. The goal of this review is to summarize the mechanisms of PBLI and their cross-linkages, exploring potential diagnostic and therapeutic targets of PBLI. We summarize the pathophysiological performance and pharmacotherapy principles of PBLI. In particular, we emphasize the crosstalk between hemorrhage and inflammation, as well as coagulation, and we propose early control of hemorrhage as the main treatment of PBLI. We also summarize several available therapy methods, including some novel internal hemostatic nanoparticles to prevent the vicious circle of inflammation and coagulation disorders. We hope that this review can provide information about the mechanisms, diagnosis, and treatment of PBLI for all interested investigators.

Epidemiological characteristics and comparative outcome of blast versus gunshot injuries of the extremities in Somalia.

BACKGROUND: War conflicts and terror-related injuries constitute a significant public health problem in Somalia. We aim to characterize and compare the injury characteristics of gunshot and blast injuries of the extremities. METHODS: The data of 333 patients with gunshot and blast injuries of the extremities over three years were retrospectively reviewed. The demographics, injury characteristics, and outcomes were analyzed. RESULTS: Most of the patients had injuries due to gunshot casualties compared with blast victims (n = 222, 66.7% vs. n = 111, 33.3%). Patients with gunshot wounds (GSW) had a more significant proportion of males than those with blast wounds (BW) (95.5% vs. 85.6%, P < 0.001). There were more open extremity fractures in GSW casualties (96.4% vs. 81.1%). The BW victims had significantly higher associated injuries (52.3% vs. 18.5%, P < 0.001). The BW group had a higher injury severity score (ISS ≥ 16 in 55%, P < 0.001). The need for an intensive care unit (ICU) admission was significantly higher in the BW patients (18% vs. 6.3%, P < 0.001); as well as the length of hospital stay (LOS) was higher in the BW group compared with the GW patients (> 2-week hospital stay in 31% vs. 19%, P < 0.04). About a 2.7% mortality rate was observed in BW (P < 0.014). CONCLUSION: Gunshot and explosion injuries comprise the majority of war and terror-related trauma of the extremities. These injury mechanisms differ in the body regions involved, the severity of the injury, duration of hospital stay, need for ICU admission, and mortality. Assessment and management of such devastating casualties require a complex and multidisciplinary approach.

Rethinking the Current "Stage-and-Wait" Paradigm.

INTRODUCTION: The experience of terrorist incidents involving a secondary explosive device that targeted rescue forces led to changes in the safety protocols of these forces in most countries of the world. These protocols are the foundation of the current "Stage-and-Wait" paradigm that prohibits the entry of Emergency Medical Services (EMS) from entering the scene and treating casualties until it is deemed safe. These guidelines were established absent of an evidence-base detailing the risk to responders and the potential consequences to the injured on-scene. The lack of clarity is compounded by the fact that different situations, as well as operational considerations, such as the length of time until bomb squad arrival at the scene versus time of massive bleeding injuries, for example, impact outcomes must be taken into account. OBJECTIVE: This study sought to shed light on this matter while employing an evidence-based approach exploring the investigations of the frequency of secondary explosion threats in terrorist attacks over the last 20 years and discussing some of the ethical challenges and ramifications ensuing. While this study does not propose an outright change to current guidelines, in light of the evidence gathered, an open review and discussion based on the findings may be beneficial. METHODS: The Global Terrorism Database (GTD) was used as the data source of bombing incidents world-wide. RESULTS: The results revealed that approximately 70 per-1,000 bombing incidents involved secondary explosions across regions and countries within the study period. CONCLUSION: This study emphasizes the need to rethink the current "Stage-and-Wait" paradigm by recommending brainstorming conferences comprised of multi-sectoral experts aimed at deliberating the matter. World-wide experts in emergency medicine, bioethics, and disaster management should cautiously consider all aspects of bomb-related incidents. These brainstorming deliberations should consider the calculated risk of secondary explosions that account for approximately 70 per-1,000 bombing incidents. This study highlights the need to re-examine the current versus new paradigm to achieve a better balance between the need to ensure EMS safety while also providing the necessary and immediate care to improve casualty survival. This ethical dilemma of postponing urgent care needs to be confronted.

[Thunder and lightning-a report on firework-associated acoustic trauma at New Year 2021/2022 (German version)]. / Schlag auf Schlag ­ Bericht über feuerwerksbedingte Knalltraumata zum Jahreswechsel 2021/2022.

BACKGROUND: This cross-sectional study aimed to assess the frequency and type of firework-associated acoustic trauma occurring in Germany on New Year's Eve 2021, despite the ban on firework sales due to the COVID-19 pandemic. MATERIALS AND METHODS: The survey period lasted 7 days, from 28 December 2021 to 03 January 2022. A questionnaire inquired date, type and treatment of trauma, sex, and age of the patient, and whether the trauma occurred when lighting or watching fireworks. Hearing impairment was classified according to the World Health Organization (WHO grades 0 to 4), and concomitant tinnitus, vertigo, or other injuries were recorded. The questionnaire was sent to the otorhinolaryngology departments of 171 hospitals in Germany. RESULTS: Of 37 otorhinolaryngology departments, 16 reported no and 21 reported 50 patients with firework-associated acoustic trauma. Mean age was 29 ± 16 years and 41 of 50 patients were males. Of these 50 patients, 22 presented without and 28 with hearing loss, 32 reported tinnitus and 3 vertigo; 20 patients were injured when lighting fireworks and 30 when watching. Hearing impairment was classified as 14â€¯× WHO grade 0, 5â€¯× WHO grade 1, 4â€¯× WHO grade 2, 2â€¯× WHO grade 3, and 3â€¯× WHO grade 4. Inpatient treatment was received by 8 patients and 11 suffered from concomitant burn injuries. CONCLUSION: Despite the sales ban, some firework-associated acoustic traumas occurred at New Year 2021/2022 in Germany. Some instances led to hospitalization, but an even higher number of unreported cases can be assumed. This study can serve as a baseline for further annual surveys to raise the awareness of the danger of seemingly harmless fireworks for the individual.

A Case Report of Combat Blast Injury Requiring Combat Casualty Care, Far-Forward ECMO, Air Transport, and All Levels of Military Critical Care.

We describe a 34-year-old soldier who sustained a blast injury in Syria resulting in tracheal 5 cm tracheal loss, cervical spine and cord injury with tetraplegia, multiple bilateral rib fractures, esophageal injury, traumatic brain injury, globe evisceration, and multiple extremity soft tissue and musculoskeletal injuries including a left tibia fracture with compartment syndrome. An emergent intubation of the transected trachea was performed in the field, and the patient was resuscitated with whole blood prehospital. During transport to the Role 2, the patient required cardiopulmonary resuscitation for cardiac arrest. On arrival, he underwent a resuscitative thoracotomy and received a massive transfusion exclusively with whole blood. A specialized critical care team transported the patient to the Role 3 hospital in Baghdad, and the DoD extracorporeal membrane oxygenation (ECMO) team was activated secondary to his unstable airway and severe hypoxia secondary to pulmonary blast injury. The casualty was cannulated in Baghdad approximately 40 hours after injury with bifemoral cannulae in a venovenous configuration. He was transported from Iraq to the U.S. Army Institute of Surgical Research Burn Center in San Antonio without issue. Extracorporeal membrane oxygenation support was successfully weaned, and he was decannulated on ECMO day 4. The early and en route use of venovenous ECMO allowed for maintenance of respiratory support during transport and bridge to operative management and demonstrates the feasibility of prolonged ECMO transport in critically ill combat casualties.

[Blast and explosion traumas-effects on the middle and inner ear based on the example of Bundeswehr foreign missions]. / Knall- und Explosionstraumata ­ Auswirkungen auf Mittel- und Innenohr am Beispiel von Auslandseinsätzen der Bundeswehr.

Despite all protective measures, blast and explosion traumas are a frequent pattern of injury in Bundeswehr missions abroad. Due to body protection measures, head injuries, particularly of the ears, are higher in number compared to injuries in other regions of the body. Perforations of the tympanic membrane are the most frequent lesions of the middle ear, acute sensorineural hearing loss is the most frequent lesion of the inner ear, often accompanied by tinnitus and dizziness. With a high spontaneous recovery rate, prompt specialist care for these injuries is provided according to medical standards comparable to those in the home country.

Blast syndrome - pathophysiology, diagnosis and treatment of blast injuries.

The incidence of explosions in large agglomerations is high even during peacetime and continues rising. Blast syndrome injuries are complex, with shock wave causing severe injuries of multiple organ systems. In situations with large numbers of injured persons, effective triage allows an early diagnosis and treatment of the highest number of victims. Treatment is challenging, and potentially conflicting therapeutic goals may alternate. This review provides an overview of the pathophysiology of blast injuries, current diagnostic algorithms and therapeutic procedures.

An Exploratory Comparison of Water-Tamped and -Untamped Explosive Breaches: Practical Applications for the Tactical Community via a Pilot Study.

BACKGROUND: Tamping explosive charges used by breachers is an increasingly common technique. The ability to increase the directional effectiveness of the charge used, combined with the potential to reduce experienced overpressure on breachers, makes tamping a desirable tool not only from an efficacy standpoint for breachers but also from a safety standpoint for operational personnel. The long-term consequences of blast exposure are an open question and may be associated with temporary performance deficits and negative health symptomatology. PURPOSE: This work evaluates breaches of varying charge weight, material breached, and tamping device used to determine the value of tamping during various scenarios by measuring actual breaches conducted during military and law enforcement training for efficacy and blast overpressure on Operators. METHODS: Three data collections across 18 charges of various construction were evaluated with blast overpressure sensors at various distances and locations where breachers would be located, to assess explosive forces on human personnel engaged in breaching activities. RESULTS AND CONCLUSIONS: Findings indicate that water tamping in general is a benefit on moderate and heavy charges but offers less benefit at a low charge with regard to mitigating blast overpressure on breachers. Reduced overpressure allows Operators to stage closer to explosives and lowers the potential for compromised reaction time. It also reduces the likelihood of negative consequences that can result from excessive overpressure exposure and allow Operators to "do more with less" in complex environments, where resource access may be limited by logistic or other limitations. However, tamping in all instances improved blast efficacy in creating successful breaches. Future studies are planned to investigate tamping mediums beyond water and environment changes, whether tamping can be used to mitigate acoustic insult, and other explosive types.

Blast-Related Traumatic Brain Injuries Secondary to Thermobaric Explosives: Implications for the War in Ukraine.

Blast-related traumatic brain injury (bTBI) is a significant cause of wartime morbidity and mortality. In recent decades, thermobaric explosives have emerged as particularly devastating weapons associated with bTBI. With recent documentation of the use of these weapons in the war in Ukraine, clinicians and laypersons alike could benefit from an improved understanding behind the dynamic interplay between explosive weaponry, its potential for bTBI, and the subsequent long-term consequences of these injuries. Therefore, we provide a general overview of the history and mechanism of action of thermobaric weapons and their potential to cause bTBI. In addition, we highlight the long-term cognitive and neuropsychiatric sequelae following bTBI and discuss diagnostic, therapeutic, and rehabilitation strategies, with the aim of helping to guide mitigation strategies and humanitarian relief in Ukraine. Thermobaric weapons produce a powerful blast wave capable of causing bTBIs, which can be further classified from primary to quaternary injuries. When modeling the hypothetical use of thermobaric weapons in Odessa, Ukraine, we estimate that the detonation of a salvo of thermobaric rockets has the potential to affect approximately 272 persons with bTBIs. In addition to the short-term damage, patients with bTBIs can present with long-term symptoms (e.g., post-traumatic stress disorder), which incur substantial financial costs and social consequences. Although these results are jarring, history has seen radical advancements in the understanding, diagnosis, and management of bTBI. Moving forward, a better understanding of the mechanism and long-term sequelae of bTBIs could help guide humanitarian relief to those affected by the war in Ukraine.

Zone 1 REBOA in a combat DCBI swine model does not worsen brain injury.

BACKGROUND: Zone 1 resuscitative endovascular balloon occlusion of the aorta has been recommended for refractory shock after a dismounted complex blast injury for the austere combat scenario. While resuscitative endovascular balloon occlusion of the aorta should enhance coronary perfusion, there is a potential risk of secondary brain injury due to loss of cerebral autoregulation. We developed a combat casualty relevant dismounted complex blast injury swine model to evaluate the effects of resuscitative endovascular balloon occlusion of the aorta zone I on intracranial pressure and cerebral edema. We hypothesized that zone 1 aortic occlusion with resuscitative endovascular balloon occlusion of the aorta would increase mean arterial pressure transmitted in excessive intracranial pressure, thereby worsening brain injury. METHODS: 50 kg male Yorkshire swine were subjected to a combination dismounted complex blast injury model consisting of blast traumatic brain injury (50 psi, ARA Mobile Shock Laboratory), tissue injury (bilateral femur fractures), and hemorrhagic shock (controlled bleeding to a base deficit goal of 10 mEq/L). During the shock phase, pigs were randomized to no aortic occlusion (n = 8) or to 30 minutes of zone 1 resuscitative endovascular balloon occlusion of the aorta (zone 1 aortic occlusion group, n = 6). After shock, pigs in both groups received a modified Tactical Combat Casualty Care-based resuscitation and were monitored for an additional 240 minutes until euthanasia/death for a total of 6 hours. Intracranial pressure was monitored throughout, and brains were harvested for water content. Linear mixed models for repeated measures were used to compare mean arterial pressure and intracranial pressure between zone 1 aortic occlusion and no aortic occlusion groups. RESULTS: After dismounted complex blast injury, the zone 1 group had a significantly higher mean arterial pressure during hemorrhagic shock compared to the control group (41.2 mm Hg vs 16.7 mm Hg, P = .002). During balloon occlusion, intracranial pressure was not significantly elevated in the zone 1 aortic occlusion group vs control, but intracranial pressure was significantly lower in the zone 1 group at the end of the observation period. In addition, the zone 1 aortic occlusion group did not have increased brain water content (zone 1 aortic occlusion: 3.95 ± 0.1g vs no aortic occlusion: 3.95 ± 0.3 g, P = .87). Troponin levels significantly increased in the no aortic occlusion group but did not in the zone 1 aortic occlusion group. CONCLUSION: Zone 1 aortic occlusion using resuscitative endovascular balloon occlusion of the aorta in a large animal dismounted complex blast injury model improved proximal mean arterial pressure while not significantly increasing intracranial pressure during balloon inflation. Observation up to 240 minutes postresuscitation did not show clinical signs of worsening brain injury or cardiac injury. These data suggest that in a dismounted complex blast injury swine model, resuscitative endovascular balloon occlusion of the aorta in zone 1 may provide neuro- and cardioprotection in the setting of blast traumatic brain injury. However, longer monitoring periods may be needed to confirm that the neuroprotection is lasting.

The Beirut Port Blast: spectrum of injuries and clinical outcomes at a large tertiary care center in Beirut, Lebanon.

PURPOSE: To describe injuries and outcomes of casualties of Beirut Port Blast treated at a large tertiary care center in Beirut, Lebanon. METHODS: A retrospective observational study assessing the spectrum of injuries, treatment, and medical outcome among casualties of the Beirut Port Blast, immediately after the blast and up to 1 week from the blast to the emergency department of the American University of Beirut Medical Center (AUBMC). RESULTS: A total of 359 patients were included. Most (n = 343, 95.6%) were adults (> 19 years), and males (56%) with a mean age of 42 ± 20 years. The most frequent mechanism of injury was a penetrating injury (45.7%), followed by other blast-related injuries (30.4%), and blunt injuries (23.4%). The most affected anatomical location were the limbs. Most (n = 217, 60.4%) patients required imaging. The most frequently administered medication was analgesics (38%), followed by anesthetics (35%), antibiotics (31%), tetanus vaccine (31%), and fluids (28%). Blood and blood products were administered in 3.8% of cases. Emergent procedures included endotracheal intubation (n = 18, 5%), surgical airway (n = 3, 0.8%), chest tube insertion (n = 4, 1.1%), thoracotomy (n = 1, 0.3%), and CPR (n = 5, 1.4%). A quarter of patients required surgical operations in the operating room (n = 85, 23.6%) and 18% required noncritical care admissions, 5.3% required critical care admissions, and 2.8% were dead on arrival. CONCLUSION: Casualties from this event had significant injuries requiring lifesaving interventions, surgical procedures, and admission to critical care units. High utilization of imaging modalities and of medications from existing stockpiles was also observed.

The Beirut Port Explosion Injuries and Lessons Learned: Results of the Beirut Blast Assessment for Surgical Services (BASS) Multicenter Study.

OBJECTIVE: This multicenter study aims to describe the injury patterns, emergency management and outcomes of the blast victims, recognize the gaps in hospital disaster preparedness, and identify lessons to be learned. SUMMARY BACKGROUND DATA: On August 4th, 2020, the city of Beirut, Lebanon suffered the largest urban explosion since Hiroshima and Nagasaki, resulting in hundreds of deaths and thousands of injuries. METHODS: All injured patients admitted to four of the largest Beirut hospitals within 72 hours of the blast, including those who died on arrival or in the emergency department (ED), were included. Medical records were systematically reviewed for: patient demographics and comorbidities; injury severity and characteristics; prehospital, ED, operative, and inpatient interventions; and outcomes at hospital discharge. Lessons learned are also shared. RESULTS: An estimated total of 1818 patients were included, of which 30 died on arrival or in the ED and 315 were admitted to the hospital. Among admitted patients, the mean age was 44.7 years (range: 1 week-93 years), 44.4% were female, and the median injury severity score (ISS) was 10 (5, 17). ISS was inversely related to the distance from the blast epicenter (r = --0.18, P = 0.035). Most injuries involved the upper extremities (53.7%), face (42.2%), and head (40.3%). Mildly injured (ISS <9) patients overwhelmed the ED in the first 2 hours; from hour 2 to hour 8 post-injury, the number of moderately, severely, and profoundly injured patients increased by 127%, 25% and 17%, respectively. A total of 475 operative procedures were performed in 239 patients, most commonly soft tissue debridement or repair (119 patients, 49.8%), limb fracture fixation (107, 44.8%), and tendon repair (56, 23.4%). A total of 11 patients (3.5%) died during the hospitalization, 56 (17.8%) developed at least 1 complication, and 51 (16.2%) were discharged with documented long-term disability. Main lessons learned included: the importance of having key hospital functions (eg, laboratory, operating room) underground; the nonadaptability of electronic medical records to disasters; the ED overwhelming with mild injuries, delay in arrival of the severely injured; and the need for realistic disaster drills. CONCLUSIONS: We, therefore, describe the injury patterns, emergency flow and trauma outcome of patients injured in the Beirut port explosion. The clinical and system-level lessons learned can help prepare for the next disaster.